16 Aug Men With Dementia More Likely to Receive Aggressive Care at End of Life
MedicalResearch.com Interview with:
Dr. Nathan Stall, MD
Geriatrician and Research fellow
Women’s College Research Institute
Dr. Paula Rochon, MD, MPH, FRCPC
Periatrician and Vice-President of Research
Women’s College Hospital
MedicalResearch.com: What is the background for this study?
Response: The advanced stages of the dementia are characterized by profound memory impairment, an inability to recognize family, minimal verbal communication, loss of ambulatory abilities, and an inability to perform basic activities of daily living. Nursing homes become a common site of care for people living with advanced dementia, who have a median survival of 1.3 years. In the advanced stages of the disease, the focus of care should generally be on maximizing quality of life.
Our study examined the frequency and sex-based differences in burdensome interventions received by nursing home residents with advanced dementia at the very end of life. Burdensome interventions include a variety of treatment and procedures that are often avoidable, may not improve comfort, and are frequently distressing to residents and their families. We found that in the last 30 days of life, nearly one in 10 nursing home residents visited an emergency department, more than one in five were hospitalized, and one in seven died in an acute care setting. In addition, almost one in 10 residents received life-threatening critical care; more than one in four were physically restrained; and more than one in three received antibiotics.
MedicalResearch.com: What are the main findings?
Response: In our study, only a minority of residents (12.1 per cent) saw a palliative care physician, but those who did were significantly less likely to experience an end-of-life transition of care and to receive antibiotics. We also found that compared with women, men had much higher rates of burdensome interventions and antibiotic therapy, and were significantly more likely to die in an acute care facility.
MedicalResearch.com: What should readers take away from your report?
Response: Despite dementia being a progressive, incurable disease and a leading cause of death in North America, many nursing home residents with advanced dementia receive burdensome interventions at the very end of life. Our findings suggest that many nursing home residents dying with advanced dementia are not perceived as having a terminal condition and most do not receive optimal palliative care. Most physicians and family members caring for individuals with this disease strongly favor palliative care for advanced dementia. Therefore, there is a pressing need for management and educational strategies to improve end of life care for those in the advanced stages of this disease.
Our finding that men are much more likely than women to experience burdensome interventions at the very end of life merits particular attention. Research in other areas highlights how implicit gender biases among health care practitioners result in women being less likely than men to be offered invasive procedures. Our study findings suggest that this gender bias may persist at the end of life, when more aggressive care—something that may have been valued at a younger age—is still provided despite such care no longer being necessarily optimal.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: This study was conducted on older nursing home residents with advanced dementia. What we have identified may be an issue more widely for older adults with dementia nearing the end of their lives.
We should also further explore the differences identified in the way that care was provided for women and men. This is a relatively new area that could add value to our understanding of how best to provide care in general and specifically at end of life.
Finally, having a palliative care assessment decreased the use of burdensome interventions at the very end of life. Previous research highlights that when nursing home residents have family members who understand the terminal prognosis and clinical course of advanced dementia, they are less likely to receive aggressive care at the end of life. Our study findings reinforce the increasing need and opportunity for geriatric medicine and palliative care involvement in nursing home residents with advanced dementia.
Stall NM, Fischer HD, Fung K, et al. Sex-Specific Differences in End-of-Life Burdensome Interventions and Antibiotic Therapy in Nursing Home Residents With Advanced Dementia. JAMA Netw Open. Published online August 16, 20192(8):e199557. doi:10.1001/jamanetworkopen.2019.9557
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